Intensive Diabetes Therapy and GFR in Type 1

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Intensive Diabetes Therapy and

GFR in Type 1 Diabetes

Wan Aisyah Wan Muda

5th April 2012


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Background

Impaired GFR is the final common pathway of

diabetic kidney disease

Risks of cardiovascular disease events and

progression to ESKD are quicker with impaired

GFR

Type 1 Diabetes at higher risk of getting

kidney disease


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Background

Combination of two study - DCCT and EDIC

Intensive therapy that lowered glycated

haemoglobin (HbA1C) levels reduced risk of

micro/macroalbuminuria, therefore reducing

long term risk of impaired GFR among Type 1

DM

Effects on development of impaired GFRwithin follow up period of 22years


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Methods

In DDCT study, 1441 Type 1 DM were randomly assignedto 6.5 years of:

a) Intensive diabetes therapy of 3 or more insulin/dayor on pump with aim of HbA1C


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Results

Impaired GFR

sustained estimated GFR of < 60ml/min/1.73m

2


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Cumulative incidence 20 yrs after

Incidence occurs in 2% of intensive therapy and5.5% of conventional therapy


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Rates of decrease in GFR

DCCT study Overall reduction in mean estimated GFR of 1.7ml/min

EDIC study Slower rate of reduction in GFR of 2.5ml/min for both

Combined : average decrease 1.27ml/min (intensive) and 1.56ml/min (conventional)


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Conclusion

Long term risk of impaired GFR significantly

lowered in persons treated for an average of

6.5 yrs with DCCT intensive therapy. This is

evident after 10 yrs of randomisation.

Impairment of GFR may be prevented in Type

1 DM with the therapy and this is also in line

with current recommendations of earlyglycemic control ( target HbA1C of < 7%)


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Discussion

Absolute incidence of impaired GFR was low. Mayreflects incidence rate of impaired GFR in Type 1DM generally.

Association of other biomarkers e.g BP, BMI, use

of antihypertensive and use of RAAS are alsomeasured to explore covariates associated withtreatment effect

Intensive therapy also provides significantreduction (73%) in risk of combined outcome ofimpaired GFR and death. Risks of impaired GFRnot influenced by number of deaths in study


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Limitations

Non randomised use of medications other thaninsulin.

?Applicable to Type 2 DM

Persons with advanced complications of diabeteswho at risk of progressive decrease in GFR maynot get same benefit as did those in treatedgroup.

Use of RAAS inhibitors discouraged during DCCTand this may give different effects if added to theintensive therapy.

Documents

Intensive Diabetes Therapy and GFR in Type 1